<form method="POST">
	<div style='width:50%;text-align:center'>
		{USERNAME_FIELD}
	</div>
	<div style='width:50%;text-align:center'>
		{PASSWORD_FIELD}
	</div>
	<div style='width:50%;text-align:center'>
		{NOTES_FIELD}
	</div>
	<div style='width:50%;text-align:center'>
		{SUBMIT_BUTTON}
	</div>
</form>